Moving From Aid to Institution

Not long ago, Rwanda only evoked nightmarish scenes of violent crisis. The New York Times described Rwanda in 1994 as a “tiny, devastated nation.”[1] Despite my denial however, 1994 was a very long time ago. And while the scars left by the genocide remain, the country has since made unprecedented strides in caring for its people. As of 2010, 90% of the people in Rwanda have health insurance with a $2 premium. This has led to dramatic decreases in malaria, maternal and infant mortality, and has cut child mortality in half. [2]

To begin with, this is a coordinated effort. Rwanda’s health ministry has instituted a policy that requires routine visits by local healthcare workers to all families living in their village. More sophisticated treatment can be carried out in hospitals if needed. In addition to the staggering success that programs like this have yielded, it has led to behavior changes in the people themselves. To me, this seems critical to a successful public health program; the people need to participate. In Rwanda, mothers are told to deliver at clinics rather than at home. Healthcare is becoming routine in Rwanda.  As basic care becomes more routine, healthcare becomes more effective at lower costs. This has been observed worldwide.[3]

The trouble is, the care that the ministry offers is still largely dependent on foreign aid. Partners in Health runs two large hospitals and a network of clinics. The Global Fund to Fight AIDS, Tuberculosis, and Malaria pays the premiums for 800,000 Rwandans in dire poverty.[4] In times of great austerity, foreign aid budgets and donations to non-profits can dry up. For this positive trend of increased access in Rwanda, the country must learn to be more self-reliant.

The good news is that this appears to be happening. The money isn’t all there yet, but it appears that the drive and leadership are. Up until now, the group AIDS Relief has been responsible for the distribution of HIV care in the country. The funding has come from the US President’s Emergency Plan for Aids Relief (PEPEFAR). The funding will now go directly to the Rwandan health ministry.[5] This is a huge step. For instance, in order to continue the high level care that had been provided by AIDS Relief, the health ministry will need to take over a campaign in Antiretroviral Therapy, which poses the challenge of delivering a steady flow of sensitive medication to many remote areas. This challenge of supply presents another opportunity for growth. Ensuring the proper delivery and distribution of these drugs will require improving the ministry’s organization and efficiency, new investments in infrastructure, and will bring the health of Rwanda further under the control of the Rwandans. All of this serves to further increase the scope and success of the health ministry.

This newfound self-sufficiency has already yielded significant results, and is the only truly sustainable solution. There may always be a place for foreign aid, but the most effective interventions appear to be homegrown.


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